Antituberculous therapy–induced fulminant hepatic failure: Successful treatment with liver transplantation and nonstandard antituberculous therapy

Abstract

Standard antituberculous therapy including isoniazid, rifampin, ethambutol, and pyrazinamide is widely used for the treatment of active tuberculosis. Its most important side effect is hepatotoxicity, ranging from asymptomatic transaminitis to fulminant hepatic failure. A 19-year-old woman was admitted to our unit due to jaundice and unconsciousness. According to her past medical history, she was diagnosed as having extrapulmonary tuberculosis and had been prescribed standard antituberculous therapy. The patient became icteric and unconscious on the fourth day after therapy initiation. She was diagnosed with drug-induced acute fulminant hepatic failure and underwent living-related liver transplantation. Nonhepatotoxic antituberculous therapy (cycloserine, ciprofloxacin, streptomycin, and ethambutol) and low-dose immunosuppressive therapy were started after transplantation. Currently the patient is very well with normal graft function 42 months after transplantation. Here we report a case of a patient with acute fulminant hepatic failure caused by isoniazid, rifampicin, or both, who was successfully treated with living-related liver transplantation and a relatively less hepatotoxic antituberculous therapy. In conclusion, liver transplantation is a feasible therapy for individuals with standard antituberculous therapy-induced hepatic failure. Nonhepatotoxic antituberculous therapy may achieve control of active tuberculosis in such individuals after transplantation. Liver abnormalities are the most important adverse effect of standard antituberculous therapy including isoniazid (INH), rifampin, ethambutol and pyrazinamide. [1][2][3][4] Such abnormalities range from asymptomatic transaminitis to acute hepatitis and fulminant hepatic failure. [1][2][3][4] Liver transplantation has become an effective treatment option for individuals with drug-induced fulminant hepatic failure. Here we report an active extrapulmonary tuberculosis case of a patient with standard antituberculous therapy-induced acute fulminant hepatic failure who was successfully treated with livingrelated liver transplantation and a relatively less-hepatotoxic antituberculous therapy regimen including cycloserine, ciprofloxacin, streptomycin, and ethambutol. CASE REPORTA 19-year-old woman was admitted to our unit with jaundice and unconsciousness. The only remarkable feature in her past medical history was presentation to her local hospital with the complaints of fever, malaise, weight loss, night sweating, and lower abdominal pain of 4 weeks' duration. Abdominal and gynecological examination revealed a palpable left ovarian mass. Sonography confirmed the diagnosis of left ovarian mass, and Abbreviation: INH, isoniazid.

Acute liver failure in Turkey: A systematic review

“…Treatment of acute liver failure in a patient with active tuberculosis has lots of difficulties. If the patient requires liver transplantation, postoperative immunosuppression with steroids can aggravate the tuberculosis, and non-standard treatment protocols become mandatory (13). The most common cause of acute liver failure in the United States (39%) and United Kingdom (57%) is paracetamol, which is usually unprescribed.…”

Acute liver failure due to antitubercular therapy: Strategy for antitubercular treatment before and after liver transplantation

“…6,7 In addition, the hepatotoxicity of anti-TB drugs is enhanced in transplant patients, mainly because of the function of the graft and interactions with immunosuppressive drugs. 7,8 Guidelines about the treatment of these patients exist in the literature, and they include information about the time to initiate ATT after ALF, the decision to reintroduce or not reintroduce standard ATT (with potentially hepatotoxic drugs), and the effectiveness of alternative nonhepatotoxic anti-TB drugs such as ofloxacin (OFX), ciprofloxacin (CFX), moxifloxacin (MOX), and amikacin (AMK). [9][10][11][12][13][14][15][16][17] These drugs have been shown to be effective and safe in patients with strains resistant to multiple drugs, but their use in patients with ALF before or after LT remains limited.…”

Acute Liver Failure in a Pediatric Patient with Disseminated Tuberculosis

“…Idilman et al [6] documented the case of a 19-year-old female who had been treated for extrapulmonary tuberculosis with the combination of rifampin, pyrazinamide, INH, and ethambutol. She presented to the hospital with jaundice and obtundation, and subsequently underwent living donor liver transplantation.…”